Fertility return after hormonal contraceptive discontinuation and associated factors among women attended Family Guidance Association of Ethiopia Dessie model clinic, Northeast Ethiopia: A cross-sectional study

Background Women who use hormonal contraception face delayed return of fertility upon discontinuation. There was limited evidence of fertility return after hormonal contraceptive discontinuation in the study area. Hence this study assessed fertility return after hormonal contraceptive discontinuation and associated factors among pregnant women attending Family Guidance Association Ethiopia (FGAE) Dessie model clinic, Northeast Ethiopia, 2019. Methods A cross-sectional study was conducted on 423 samples selected by using systematic random sampling. Data were collected by face-to-face interview using a pretested and structured questionnaire and reviewing client records. Data were entered using Epi Data version 3.1 and analyzed using SPSS version 23. Both bi-variable and multivariable binary logistic regressions were used to identify predictors of delayed fertility return. Adjusted odds ratio (AOR) along with a 95% Confidence Interval (CI) was used to measure the strength and the direction of the association and statistical significance was declared at a P-value less than 0.05. Result The proportion of fertility return among currently pregnant women after discontinuation of any hormonal contraceptive methods was 88.6% (95% CI; (85.6%-92%)). The proportion of fertility return among Depo-Provera, implant, Intrauterine Contraceptive Device (IUCD), and Oral Contraceptive Pill (OCP) users was 75%, 99.1%, 100%, and 97.8% respectively. Age, (AOR = 5.37, (95% CI; (1.48, 13.6)) and using Depo-Provera (AOR = 4.82, 95% CI; (1.89, 14.2)) had a significant association with delayed fertility return. Conclusions The proportion of fertility return among women after discontinuation of any hormonal contraceptive methods was high. Age and using Depo-Provera had a positive association with delayed fertility return. This study recommends a contraceptive counseling approach that addresses concerns about delay in the return of fertility after hormonal contraceptive discontinuation to avoid confusion among family planning users.


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Delayed fertility return or impaired fertility had a significant impact on women's health. It lower 54 contraceptive use irrespective of actual desire, it leads to divorce, stigma and discrimination, 55 isolation, intimate partner violence, murder, mental health disorders, and suicide [3][4][5][13][14][15] for not using contraceptive methods might be due to fertility delay associated with contraceptive 68 utilization.

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There was limited evidence regarding fertility return after contraceptive discontinuation in the 70 study area. So, this study aimed to assess fertility return after contraceptive discontinuation and for ANC during the data collection period were included and those women who became pregnant 79 without using any contraceptive method and due to contraceptive failure were excluded from the 80 study.

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Sample size and sampling procedure 82 The sample size was determined by using single population proportion formula by considering the 83 proportion of delayed fertility return as 50% since no study was done in Ethiopia, 95% confidence 84 level and 5% margin of error. Thus, the final sample size after adding a 10 % non-response rate   (S1 table).

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Socio-demographic characteristics 125 In this study, a total of 402 pregnant women were involved and making a response rate of 94.5%.

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The median age of the respondents was 28 years with IQR of 4 years. Three hundred eighty 127 (94.5%) of pregnant women were married, 22(5.5%) of pregnant women were single and divorced 128 7 and 361(89.8%) of pregnant women were Amhara in their ethnicity respectively. Two hundred 129 sixteen (53.7%) pregnant women were orthodox tewahido followers, 203(50.5%) of women earn 130 less than or equal to 5,000 Ethiopian birr and 392 (97.5%) of women live in urban areas 131 respectively. One hundred ninety-six (48.8%) of pregnant women were educated up to college and 132 university level and 143(35.6%) of women were government employed respectively (Table 1) One hundred thirty-one (32.6%) of pregnant women ever drink alcohol in their lifetime,    Proportion of fertility return 161 The proportion of delayed fertility return experienced by pregnant women after discontinuation of 162 any modern contraceptive methods before the current pregnancy was 11.4% (95% CI; (8-14.4%)).

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The median time of fertility return among pregnant women after discontinuation of any modern 167 contraceptive methods before the current pregnancy was 6 months with IQR of 8 months. The were 6.2 times more likely to experience fertility delay upon discontinuation as compared to 176 women who used IUCD and OCP (AOR=6.22, (95% CI; 5.23, 13.3)) ( Table 4).

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The proportion of delayed fertility return experienced by pregnant women after discontinuation of 185 any modern contraceptive methods before the current pregnancy was 11.4%. The proportion of 186 delayed fertility return among Depo-Provera, implant, IUCD, and OCP users before the current 187 pregnancy was (25%), (0.9%), 0% and (2.2%) respectively. Age and using Depo-Provera had a 188 positive association with delayed fertility return.

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The proportion of delayed fertility return (inability to conceive within twelve months) experienced 190 by pregnant women after discontinuation of any modern contraceptive methods was 11% similar 191 to a study done in England, which showed that 12 % of the participants experienced failure to 192 conceive within one year after discontinuation of any contraceptive method [27]. The proportion of delayed fertility return experienced by Depo-Provera users before the current pregnancy was 194 25% similar to another study which was 22.26% [19]. 195 But, the proportion of delayed fertility return experienced by implant, IUCD, and OCP users was 196 0.9%, 0%, and 2.2%, respectively, which is low in contrast to a meta-analysis study which 197 indicated that the proportion of delayed fertility return experienced by implant, IUCD, and OCP 198 users was 25.3%, 15.25%, and 12.06% [19]. Similarly, the proportion of delayed fertility return 199 experienced by IUCD users was also low as compared to a study done in the United States of 200 America (USA) which was 19% [18]. This could be due to differences in the study setting and 201 study population.

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In this study, age has a significant association with delayed fertility return. A unit increase in age 203 delay fertility return by 1.1 times. Different studies also revealed that as age increases fertility 204 return will be delayed [27][28][29]. The reason behind this could be the number of eggs decreases as 205 women get older due to a fixed number of eggs in the ovary. The other reason could be as age 206 increases, women will be at higher risk of disorders that can affect fertility, such as uterine 207 fibroids and endometriosis. Moreover, as age increases, the remaining eggs in older women are 208 more likely to have abnormal chromosomes.

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Using Depo-Provera had a positive association with delayed fertility return. A global handbook on 210 family planning for health care providers demonstrated that Depo-Provera causes a delayed 211 fertility return [15]. This could be due to Depo-Provera can stay in the body system longer than 212 the other birth control methods, so that the clearance of progestin from the serum takes a long 213 time and the meantime to ovulation become delayed. On the other hand, Depo-Provera causes 214 excessive weight gain; this leads the women to stop ovulation and get irregular menstrual cycles.

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Once women stop ovulation, they would not be able to conceive and therefore it delays fertility 216 return.

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This study has limitations. Some variables like history of alcohol use, chat chewing, duration of 218 contraceptive use and duration of contraceptive discontinuation until the current pregnancy will 219 be affected by recall bias. Being a facility-based study will also underestimate delayed fertility 220 return as it is prone to miss defaulters and delayed visitors to their ANC appointment.

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The proportion of delayed fertility return experienced by pregnant women after discontinuation of 223 any modern contraceptive methods before the current pregnancy was consistent with other studies.

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But the proportion of delayed fertility return experienced by implant, IUCD, and OCP users before  We would like to express our deepest gratitude to Wollo University for providing financial support 243 to conduct this research. Finally, we would like to extend our appreciation for FGA Dessie Model 244 Clinic Head and staff, study participants, data collectors, and supervisor for their cooperation 245 during the data collection process.